Pharmacy & Formulary
EHP provides prescription drug benefits for several EHP employer groups. However, these benefits may not be applicable to certain employers. Please refer to your patient’s schedule of benefits for detailed information about employer coverage.
Pharmacy Formulary
The EHP Formulary, called the Advanced Control Formulary (effective 10/01/2023), is a useful reference and informational tool. It can assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The formulary is updated on a quarterly basis or as needed and when a new generic or brand-name medication becomes available, and as discontinued drugs are removed from the marketplace.
If a formulary medication is not appropriate, medical necessity prior authorization may be obtained. To do this, you may submit a prior authorization request along with clinical documentation, including treatment failure of covered drugs. Without a prior authorization for medical necessity, the member may be required to pay the full cost of the medication.
The EHP Advanced Control Formulary is subject to change at any time. The formulary is updated on a regular basis, including when new generic or brand-name medications become available and as discontinued drugs are removed from the marketplace. You can review additions/removals to the Advanced Control Formulary:
See if the medication is subject to Utilization Management edits (prior authorization, quantity limit, or step therapy). Registration is required for first-time use.
Please note: Effective 01/01/2024, the EHP Formulary will be the Advanced Control Choice Formulary. Formulary additions and removals to the Advanced Control Choice Formulary that will be effective 01/01/2024 may be reviewed here.
Prior Authorization
Certain medications require prior authorization before coverage is approved to assure medical necessity, clinical appropriateness, and/or cost effectiveness. Coverage of these drugs is subject to specific criteria approved by physicians and pharmacists on the Pharmacy and Therapeutics Committee. Established criteria are based on medical literature, physician expert opinion, and Food and Drug Administration (FDA) approved labeling information.
Providers may request prior authorization electronically or by calling CVS/caremark's Prior Authorization department at 1-800-294-5979.
Quantity Limits
Certain prescription medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the FDA, current medical literature, and input from a committee of physicians and pharmacists.
The three types of quantity limits include the following:
- Coverage limited to one dose per day for drugs that are approved for once daily dosing
- Coverage limited to specific number of units over a defined time frame
- Coverage limited to approve maximum daily dosage
When medically necessary, an exception to quantity limits can be requested. If your patient's medical condition warrants use of quantities greater than listed quantities for each drug, you may request prior authorization for a higher quantity. Providers may request prior authorization electronically or by calling CVS/caremark's Prior Authorization department at 1-800-294-5979.
Step Therapy
Certain covered medications are required to satisfy specific step therapy criteria. Step therapy criteria simply means that for certain drug products, members must first have tried one or more prerequisite medications to treat their condition before other medications are covered through their benefit.
When medically necessary, providers may request an exception to the step therapy requirement and ask for prior authorization. Providers may request prior authorization electronically or by calling CVS/caremark's Prior Authorization department at 1-800-294-5979.
Printed copies of EHP's pharmaceutical management procedures are available to providers upon request. Please call (888) 819-1043 and select option 4 to request this information.
Copay Tiers
EHP members covered by the EHP pharmacy benefit have a three-tier drug benefit. Each tier has a different copay or out-of-pocket expense. The EHP Advanced Control Formulary™ consists of the following tiers:
- Tier One: Generic
Generic drugs have the lowest out-of-pocket cost for members and are usually placed on Tier 1. Generic products are displayed in the formulary in lowercase italics. - Tier Two: Preferred Brand
Preferred brand-name drugs have a significant safety or efficacy advantage compared to similar agents. These agents have an intermediate out-of-pocket cost for members. These products are usually placed on Tier 2 and displayed in the formulary in CAPS. - Tier Three: Non-preferred Brand
Non-preferred brand-name drugs do not have a significant, clinical advantage in terms of effectiveness, safety, and clinical outcomes compared to similar agents. These drugs have higher out-of-pocket cost for members. In most cases, there will be Tier 1 or Tier 2 alternatives for products found in this tier. Non-preferred brand-name drugs covered under the pharmacy benefit are not displayed in the formulary and may process in Tier 3.
If a member or a provider requests a brand-name drug for which a generic equivalent is available, the member may pay the Tier 3 copay plus the difference between the brand and generic cost.
Retail Pharmacy Network
The retail pharmacy network includes over 64,000 pharmacies nationwide. The network includes most chain retailers and independent pharmacies. Search for a participating network pharmacy.
Generic Substitution
EHP encourages the use and prescribing of generic medications. If the prescriber or member chooses a brand-name drug with a generic equivalent, the member may be required to pay a higher cost share. Cost share for members covered under the EHP pharmacy benefit vary by employer plan design. Cost share for brand-name drugs with a generic equivalent available is determined by the employer's Summary Plan Description (SPD).
Learn more about generic medications.
Drug Safety Information
Visit the CVS Caremark website to find the latest drug safety information, including how to take the medication, the possible side effects, and drug interactions.
Pharmacy Compounded Drugs
To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications, when rejected at the pharmacy, may require prior authorization. Providers may request prior authorization electronically or by calling CVS/caremark's Prior Authorization department at 1-800-294-5979. The provider must provide clinical documentation to support the request and demonstrate that an FDA approved commercially-available product is not clinically appropriate for the member.
Specialty Medications
Specialty medications are usually high-cost prescription medications used to treat complex chronic conditions. These drugs typically require special storage and handling, and may not be readily available at a local pharmacy. Specialty medications may also have side effects that require pharmacist and/or provider monitoring.
Specialty Medications - Pharmacy Benefit These medications are self-administered and processed through a member’s pharmacy benefit. These medications are available at a local retail or specialty pharmacy and may require prior authorization. Providers may request prior authorization electronically or by calling CVS Caremark's Prior Authorization department at 1-800-294-5979.
Specialty Medications – Medical Benefit These medications are administered by a provider or under supervision of a provider and processed through a member’s medical benefit. Providers may supply these medications and bill the health plan for the medication and related administration using HCPCS Codes or J codes.
View the HCPCS Codes that require prior authorization for medical necessity, and the criteria for these medications.
How to request a medical benefit drug prior authorization:
- Submit electronic prior authorization requests through NovoLogix using the EHP HealthLINK secure provider portal.
- If HealthLINK is not able to be accessed, contact NovoLogix for assistance by calling: 844-345-2803.
PrudentRx Program
EHP* offers members a program from CVS Health and PrudentRx that will help members save money when they fill eligible specialty medications. This program is effective Jan. 1, 2024. All medications on the PrudentRx Specialty Drug List are subject to a 30% coinsurance. However, members that participate in the PrudentRx program will have a $0 out-of-pocket responsibility for the covered specialty medication.
View the PrudentRx Specialty Drug List (updated monthly)
Medications on the PrudentRx Specialty Drug List may only be obtained from Johns Hopkins Outpatient Pharmacies and CVS Specialty Pharmacies.
Prescriptions for eligible specialty medication can be sent to either of these pharmacies by calling:
- CVS Specialty Pharmacy: 800-237-2767
- Johns Hopkins Outpatient Pharmacy: 410-288-6100